A Complete Guide to Hepatic Encephalopathy

Medically Reviewed By Youssef (Joe) Soliman, MD
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Hepatic encephalopathy occurs when severe liver disease affects your brain function. When your liver cannot remove toxins in your blood, the toxins can travel to your brain and cause damage. Hepatic encephalopathy can be acute or chronic. With treatment, the condition may be reversible. Without treatment, it can result in coma or death. 

Some people have such subtle symptoms that they do not receive a diagnosis. This makes it challenging to know how prevalent hepatic encephalopathy is. Researchers estimate that about 70% of people with cirrhosis, which is scarring in the liver, develop hepatic encephalopathy. 

This article provides an overview of hepatic encephalopathy, including causes, symptoms, and available treatments.

How do doctors classify hepatic encephalopathy?

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Medical professionals classify hepatic encephalopathy in two ways: by type or by grade.


There are three types of hepatic encephalopathy. Doctors determine the type by the cause and other health conditions that come with the condition: 

  • Type A: This type comes on suddenly as acute liver failure, usually occurring with swelling in the brain.
  • Type B: This type does not result from liver disease, but from a portosystemic shunt. This shunt allows blood that usually supplies the liver to flow into your body’s bloodstream instead. Toxins can build up because the liver is not removing them.
  • Type C: This type develops if you have cirrhosis.


There are five grades, or stages, of hepatic encephalopathy:

  • Grade 0: The changes in brain function may be so minimal that they are hard to detect. You might notice subtle changes in your memory, concentration, or thinking, such as increased difficulty in your work performance.
  • Grade 1: You may notice mild changes, such as trouble sleeping or feeling more irritable than usual. 
  • Grade 2: There are moderate changes in your brain function. You may notice your hands shaking, and writing may be difficult. You may become forgetful and experience slurred speech
  • Grade 3: This grade is considered severe hepatic encephalopathy. It comes with confusion or extreme fatigue. Others around you might notice you acting strangely. You might have trouble remembering what day it is or where you are. 
  • Grade 4: The final stage of hepatic encephalopathy is a state of unconsciousness known as hepatic coma. 

What are the causes of hepatic encephalopathy?

Doctors are unsure of the cause, but they know that the resulting brain damage comes from a buildup of toxins in the bloodstream. Your liver typically removes these toxins, such as ammonia, preventing them from causing damage. However, a damaged liver is unable to perform this function.

Hepatic encephalopathy affects males and females (assigned at birth) equally.

These factors may increase your chance of developing hepatic encephalopathy:

In addition, some medications that affect your nervous system or suppress the immune system may increase your risk. These medications include tranquilizers, such as barbiturates or benzodiazepines.

What are the symptoms of hepatic encephalopathy?

The symptoms of hepatic encephalopathy depend on the cause. Typically, you can expect:

  • trouble thinking or concentrating
  • difficulty writing or using your hands
  • impaired judgment
  • forgetfulness
  • confusion

As hepatic encephalopathy gets worse, you might experience:

How do doctors diagnose hepatic encephalopathy?

Doctors diagnose hepatic encephalopathy following a review of your medical history, a physical examination, and an assessment of your symptoms.

Blood tests

Blood tests can aid in the diagnostic process. These tests check your red blood cell count and levels of ammonia, sodium, and potassium.

Imaging tests

Doctors may perform certain imaging tests, such as MRI and CT scans, to look at the structure of your brain. Additionally, an electroencephalogram (EEG) can help doctors assess the brain’s electrical activity. 

What are the treatments for hepatic encephalopathy?

If the hepatic encephalopathy is not chronic and you are experiencing a flare-up, your doctor might recommend limiting your protein intake. Red meat, poultry, fish, and eggs are high in protein. Vegetable proteins, such as quinoa, tofu, and lentils, may be better options.

If an infection or bleeding in the gastrointestinal tract is the cause, medications may help relieve symptoms. However, you may need a procedure to treat the infection or stop any bleeding. Your doctor may have you stop taking certain medications.

After addressing the underlying cause, your care team will work to lower the levels of ammonia and other harmful substances in your blood. The medication lactulose can produce more bowel movements to flush toxins out of your body. Antibiotics can help prevent the growth of harmful bacteria that produce these toxins.

If hepatic encephalopathy affects your breathing, doctors may insert a tube in your throat to help you breathe. In some cases, a liver transplant may be necessary. 

What is the outlook for people with hepatic encephalopathy?

It is essential to diagnose and treat hepatic encephalopathy as early as possible. This prevents complications or long-term liver or brain damage. In some cases, hepatic encephalopathy may continue to progress even with timely treatment.

The treatments for hepatic encephalopathy will not cure the condition, and some people may need a liver transplant. However, a liver transplant may not be easily available. Easing symptoms becomes an important part of treatment.

What are some potential complications of hepatic encephalopathy?

If left untreated, hepatic encephalopathy can progress to:

Can you prevent hepatic encephalopathy?

Preventing or managing liver disease before it progresses may prevent hepatic encephalopathy. Getting hepatitis A and hepatitis B vaccines, and practicing these healthy habits may help:

  • eating a healthy diet and limiting foods high in fat
  • managing your weight
  • drinking alcohol in moderation or avoiding it entirely
  • avoiding needles that others have used, including finger sticks for checking blood sugar
  • washing your hands after using the bathroom


Hepatic encephalopathy is a condition that occurs when liver disease causes toxins to build up in the bloodstream and travel to the brain. The resulting brain damage can cause personality changes, confusion, and fatigue.

Treatment depends on the cause and severity of the hepatic encephalopathy. With early detection and prompt treatment, hepatic encephalopathy may be reversible. 

Talk with your doctor about your risk and treatment options for hepatic encephalopathy.

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Medical Reviewer: Youssef (Joe) Soliman, MD
Last Review Date: 2022 Jun 25
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THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
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